Division of Medical Assistance Clinical Coverage Policy No.: 1L-2 Moderate (Conscious) Sedation Original Effective Date: December 1, 2007

Division of Medical Assistance
Moderate (Conscious) Sedation
Clinical Coverage Policy No.: 1L-2

Original Effective Date: December 1, 2007
Table of Contents
1.0
Definition of the Service..................................................................................................................1

1.1
Minimal Sedation (Anxiolysis)...........................................................................................1
1.2
Moderate Sedation/Analgesia (Conscious Sedation) ......................................................1
1.3
Deep Sedation/Analgesia ....................................................................................................1
1.4
General Anesthesia .............................................................................................................2
1.5
Administration ....................................................................................................................2
2.0
Eligible Recipients ...........................................................................................................................3

2.1
General Provisions..............................................................................................................3
2.2
EPSDT Special Provision: Exception to Policy Limitations for Recipients under
21 Years of Age ..................................................................................................................3
3.0
When the Service Is Covered...........................................................................................................4

3.1
General Criteria...................................................................................................................4
4.0
When the Service Is Not Covered....................................................................................................4

4.1
General Criteria...................................................................................................................4
4.2
Specific Criteria ..................................................................................................................5
5.0
Requirements for and Limitations on Coverage ..............................................................................5

5.1
Prior Approval ....................................................................................................................5
5.2
Moderate Sedation Services................................................................................................5
5.3
Supervision .........................................................................................................................5
5.4
Monitoring ..........................................................................................................................6
5.5
Time Factors .......................................................................................................................7
6.0
Providers Eligible to Bill for the Service .........................................................................................7
7.0
Additional Requirements .................................................................................................................7

7.1
Medical Record Documentation .........................................................................................7
7.2
Records Retention...............................................................................................................7
8.0
Policy Implementation/Revision Information..................................................................................8
Attachment A: Claims-Related Information .................................................................................................9

A.
Claim Type .........................................................................................................................9
B.
Diagnosis Codes .................................................................................................................9
C.
Procedure Codes .................................................................................................................9
D.
Modifiers...........................................................................................................................10
E.
Place of Service ................................................................................................................10
F.
Reimbursement .................................................................................................................10
G.
Billing Guidelines .............................................................................................................10
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1.0

Definition of the Service

Moderate (conscious) sedation is the use of medication to depress the level of consciousness in a
patient while allowing the patient to continually and independently maintain a patent airway and
respond appropriately to verbal commands and/or gentle stimulation.
Many organizations have defined different levels of sedation. These definitions are consistent
among the organizations and are clearly outlined by the American Society of Anesthesiologists
(ASA).
Continuum of Depth Sedation Definition of General Anesthesia and Levels of
Sedation/Analgesia*
Minimal
Sedation
(Anxiolysis)
Responsiveness
Airway
Spontaneous
Ventilation
Cardiovascular
Function
Normal
response to
verbal
stimulation
Unaffected
Unaffected
Unaffected
Moderate
Deep
General
Sedation/Analgesia Sedation/Analgesia Anesthesia
(Conscious
Sedation)
Purposeful response Purposeful response Unarousable
to verbal or tactile
following repeated
even with
stimulation
or painful
painful
stimulation
stimulus
No intervention
Intervention may be Intervention
required
required
often required
Adequate
May be inadequate
Frequently
inadequate
Usually maintained Usually maintained
May be
Impaired
*Approved by ASA House of Delegates on October 13, 1999, and amended on October 27, 2004.
1.1
Minimal Sedation (Anxiolysis)

Minimal sedation (anxiolysis) is a drug-induced state during which patients respond
normally to verbal commands. Although cognitive function and coordination may be
impaired, ventilatory and cardiovascular functions are unaffected.
1.2
Moderate Sedation/Analgesia (Conscious Sedation)

Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of
consciousness during which patients respond purposefully to verbal commands, either
alone or accompanied by light tactile stimulation. No interventions are required to
maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
1.3
Deep Sedation/Analgesia
Deep sedation/analgesia is a drug-induced depression of consciousness during which
patients cannot be easily aroused but respond purposefully following repeated or painful
stimulation. The ability to independently maintain ventilatory function may be impaired.
Patients may require assistance in maintaining a patent airway, and spontaneous
ventilation may be adequate. Cardiovascular function is usually maintained.
CPT codes, descriptors, and other data only are copyright 2006 American Medical Association.
CDT-2007/2008 (including procedure codes, descriptions, and other data) is copyrighted by the
American Dental Association. 2006 American Dental Association.
All rights reserved. Applicable FARS/DFARS apply.
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1

1.4

General Anesthesia
General anesthesia is a drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in maintaining a patent
airway, and positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.
1.5
Administration
Moderate sedation can be administered by qualified personnel under the direction of a
physician or dentist (see the Board of Dental Examiners credentialing process at
http://www.ncdentalboard.org/pdf/RulesRevised.pdf). Physicians or dentists providing
moderate sedation must be qualified (and credentialed) to recognize deep sedation,
manage its consequences, and adjust the level of sedation to a moderate or minimal level.
The continued assessment of the effects of sedative or analgesic medications on the level
of consciousness and on cardiac and respiratory function is an integral element of this
service. Any provider who delivers sedation should also recognize that different levels of
sedation are possible, and they are not specific to a given drug. Because selection is a
continuum, it is not always possible to predict how an individual patient will respond.
Hence, the recommendation (also a recommendation of the Joint Commission) that a
provider of sedation should be able to manage or rescue a patient from one level of
sedation deeper than that which was intended. Rescue of a patient from a deeper level
of sedation than intended is an intervention by a practitioner proficient in airway
management and advanced life support. The qualified (and credentialed) provider
corrects adverse physiologic consequences of the deeper-than-intended level of sedation
(such as hypoventilation, hypoxia, and hypotension) and returns the patient to the
originally intended level of sedation.
In some circumstances a second physician (or nurse anesthetist or critical care nurse
practitioner) who has been trained and credentialed to administer and manage deep
sedation may be required, in addition to the trained observer, to monitor the moderate
sedation. In these instances, this second physician may take complete responsibility for
ordering and administering the medications for sedation.
Consultation with an anesthesiologist should be considered when deep sedation may be
required either because a procedure is very painful or the patient is required to be very
still or when patients are at increased risk for sedation-associated complications.
The definition for moderate sedation for non-neonatal pediatric patients is the same as for
adult patients: a depressed level of consciousness with the ability to independently and
continuously maintain a patent airway and respond appropriately to physical stimulation.
As with adult patients, pediatric patients may need to be sedated for surgical or diagnostic
procedures. The American Academy of Pediatrics and the American Academy of
Pediatric Dentistry have recently published guidelines for monitoring and management of
pediatric patients during and after sedation for diagnostic and therapeutic procedures
(Pediatrics 2006; 118 (6): 2587-2602).
Moderate (conscious) sedation includes all of the six possible routes of administration
(intramuscular, intravenous, oral, rectal, intranasal, and inhalation).
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2.0

Eligible Recipients
2.1
General Provisions
Medicaid recipients may have service restrictions due to their eligibility category that
would make them ineligible for this service.
2.2
EPSDT Special Provision: Exception to Policy Limitations for Recipients

under 21 Years of Age
42 U.S.C. 1396d(r) [1905(r) of the Social Security Act]
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid
requirement that requires the state Medicaid agency to cover services, products, or
procedures for Medicaid recipients under 21 years of age if the service is medically
necessary health care to correct or ameliorate a defect, physical or mental illness, or a
condition [health problem] identified through a screening examination** (includes any
evaluation by a physician or other licensed clinician). This means EPSDT covers most of
the medical or remedial care a child needs to improve or maintain his/her health in the
best condition possible, compensate for a health problem, prevent it from worsening, or
prevent the development of additional health problems. Medically necessary services will
be provided in the most economic mode, as long as the treatment made available is
similarly efficacious to the service requested by the recipients physician, therapist, or
other licensed practitioner; the determination process does not delay the delivery of the
needed service; and the determination does not limit the recipients right to a free choice
of providers.
EPSDT does not require the state Medicaid agency to provide any service, product, or
procedure
a.
that is unsafe, ineffective, or experimental/investigational.
b.
that is not medical in nature or not generally recognized as an accepted method of
medical practice or treatment.
Service limitations on scope, amount, duration, frequency, location of service, and/or
other specific criteria described in clinical coverage policies may be exceeded or may not
apply as long as the providers documentation shows that the requested service is
medically necessary to correct or ameliorate a defect, physical or mental illness, or a
condition [health problem]; that is, provider documentation shows how the service,
product, or procedure will correct or improve or maintain the recipients health in the best
condition possible, compensate for a health problem, prevent it from worsening, or
prevent the development of additional health problems.
**EPSDT and Prior Approval Requirements
a.
If the service, product, or procedure requires prior approval, the fact that the
recipient is under 21 years of age does NOT eliminate the requirement for prior
approval.
b.
IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval
is found in the Basic Medicaid Billing Guide, sections 2 and 6, and on the EPSDT
provider page. The Web addresses are specified below.
Basic Medicaid Billing Guide: http://www.ncdhhs.gov/dma/medbillcaguide.htm
EPSDT provider page: http://www.ncdhhs.gov/dma/EPSDTprovider.htm
11202007

3.0

When the Service Is Covered

IMPORTANT NOTE: EPSDT allows a recipient less than 21 years of age to receive services in
excess of the limitations or restrictions below and without meeting the specific criteria in this
section when such services are medically necessary health care services to correct or ameliorate
a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows
how the service, product, or procedure will correct or improve or maintain the recipients health
in the best condition possible, compensate for a health problem, prevent it from worsening, or
EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF
PRIOR APPROVAL IS REQUIRED. For additional information about EPSDT and prior
approval requirements, see Section 2.0 of this policy.
3.1
General Criteria
Moderate sedation is covered when it is medically necessary and
a.
the procedure is individualized, specific, and consistent with symptoms or
confirmed diagnosis of the illness or injury under treatment, and not in excess of
the recipients needs;
b.
the procedure can be safely furnished, and no equally effective and more
conservative or less costly treatment is available statewide; and
c.
the procedure is furnished in a manner not primarily intended for the convenience
of the recipient, the recipients caretaker, or the provider.
4.0
When the Service Is Not Covered

4.1
General Criteria
Moderate sedation is not covered when
a.
the recipient does not meet the eligibility requirements listed in Section 2.0;
b.
the recipient does not meet the medical necessity criteria listed in Section 3.0;
c.
the procedure unnecessarily duplicates another providers procedure; or
d.
the procedure is experimental, investigational, or part of a clinical trial.
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4.2

Specific Criteria
Moderate sedation is not covered when
a.
the medication is given for postoperative pain relief, premedication, or pain control
during labor and delivery; or
b.
moderate (conscious) sedation is included as part of the procedure (see Appendix
G of the CPT manual).
5.0
Requirements for and Limitations on Coverage

5.1
Prior Approval
Prior approval is not required.
5.2
Moderate Sedation Services

Moderate sedation includes the following services, which are not reported separately:
a.
assessment of the patient
b.
establishment of IV access and fluids to maintain patency
c.
administration of oxygen
d.
administration of agent
e.
maintenance of sedation
f.
monitoring of oxygen saturation, cardiac rate and rhythm, and blood pressure
g.
recovery
5.3
Supervision
Sedation will be administered either by or under the immediate direct supervision of a
physician or dentist who has been trained and credentialed to administer and monitor
moderate sedation. (Dental credentialing information is available from the North Carolina
Board of Dental Examiners at http://www.ncdentalboard.org/pdf/RulesRevised.pdf,
section 16 Q, General Anesthesia & Sedation.) The physician or dentist is responsible for
the following:
a.
completion of history and physical
b.
completion of informed consent
c.
checking the adequacy of the pre-procedure fast according to these
recommendations:
11202007

d.
e.
f.
5.4

Appropriate Intake of Food and Liquids Before Elective Sedation

Ingested Material
Minimum Fasting
Period, h
Clear liquids: water, fruit juices without pulp,
2
carbonated beverages, clear tea, black coffee
Breast milk
4
Infant formula
6
Nonhuman milk: because nonhuman milk is similar to
6
solids in gastric emptying time, the amount ingested
must be considered when determining an appropriate
fasting period
6
Light meal: a light meal typically consists of toast and
clear liquids. Meals that include fried or fatty foods or
meat may prolong gastric emptying time; both the
amount and type of foods ingested must be considered
when determining an appropriate fasting period
(Source: American Society of Anesthesiologists. Practice guidelines for
preoperative fasting and the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: application to healthy patients undergoing elective
proceduresa report of the American Society of Anesthesiologists. Available at
http://www2.asahq.org/publications/pc-178-4-practice-guidelines-forpreoperative-fasting.aspx; publication no. 30503-8PP-8PP.)
ordering of the medications
direction and provision of emergency interventions as necessary
checking for basic equipment:
1.
suction: size-appropriate suction catheters and a functioning suction
apparatus
2.
oxygen: adequate oxygen supply and functioning flow meters
3.
airways: size-appropriate airway equipment (nasopharyngeal and
oropharyngeal airways, laryngoscope blades, endotracheal tubes, face masks,
bag-valve-mask or equivalent device)
4.
drugs: all the basic drugs needed to support life during an emergency
5.
monitorsfunctioning pulse oximeter with size-appropriate probes and other
monitors as appropriate for procedures such as non-invasive blood pressure,
end-tidal carbon dioxide, ECG, stethoscope
6.
intravenous access
Monitoring
All patients receiving moderate sedation must be monitored throughout the procedure as
well as the recovery phase by numerous physiologic measurements. The physiologic
measurements include but are not limited to continuous monitoring of oxygen saturation
and cardiac rate and rhythm and intermittent recording of respiration rate, blood pressure,
and level of consciousness. Administration of supplemental oxygen is encouraged for all
patients undergoing moderate sedation.
Qualified individuals responsible for monitoring the patient may not be engaged in any
other activity during the period of moderate sedation.
11202007


These individuals are responsible for the following:

a.
patient assessment
b.
administration of medications per physicians or dentists orders. If a second
physician is fully responsible for monitoring sedation, that individual may assume
responsibility for ordering and administering the medications for sedation.
c.
uninterrupted observation and monitoring of the patient from time of moderate
sedation until time of discharge
d.
medical record documentation (see Section 7.1)
e.
provision of appropriate emergency intervention as necessary
5.5
Time Factors
Intraservice time starts with the administration of the sedation agent(s), requires
continuous face-to-face attendance, and ends at the conclusion of personal contact by the
physician or dentist providing the sedation.
6.0
Providers Eligible to Bill for the Service

Providers who meet Medicaids qualifications for participation and are currently enrolled with the
N.C. Medicaid program are eligible to bill for moderate sedation when the service is within the
scope of their practice.
7.0
Additional Requirements
All providers must comply with all applicable state and federal laws and regulations.
7.1
Medical Record Documentation

The following information must be documented in the patients medical record:
a.
Dosage, route, time, and effect of all drugs used
b.
Type and amount of intravenous fluids administered (including blood and/or blood
products), monitoring devices, or equipment used
c.
Name and medical or dental title of staff providing and monitoring moderate
sedation
d.
Cardiac rate and rhythm, blood pressure, respiratory rate, oxygen saturation, and
level of consciousness are charted at intervals appropriate to the level of sedation
e.
Return to normal level of consciousness, awareness and responsiveness, and
airway protective reflexes at the completion of the moderate sedation interval
7.2
Records Retention
In accordance with10A NCAC 22F.0107, all providers shall keep and maintain all
financial, medical, or other records necessary to fully disclose the nature and extent of
services furnished and claimed for reimbursement. These records shall be retained for a
period of not less than 5 years from the date of service.
Note: Dental providers must additionally comply with the requirements and limitations
stated in Clinical Coverage Policy 4A, Dental Services (available on DMAs Web site at
http://www.ncdhhs.gov/dma/mp/mpindex.htm).
11202007

8.0

Policy Implementation/Revision Information

Original Effective Date:
Revision Information:
Date
11202007
Section Revised
Change


Attachment A: Claims-Related Information

Reimbursement requires compliance with all Medicaid guidelines, including obtaining
appropriate referrals for recipients enrolled in the Medicaid managed care programs.
A. Claim Type
Professional (CMS-1500/837P transaction)
Dental (ADA/837D transaction)
B. Diagnosis Codes
Providers must bill the ICD-9-CM diagnosis codes(s) to the highest level of specificity that
supports medical necessity.
C. Procedure Codes
Moderate sedation does not include minimal sedation (anxiolysis), deep sedation, or
monitored anesthesia care. The following CPT codes for moderate sedation are covered:
CPT
Code
99143
99144
99145
99148
99149
11202007
CPT Code Description

Moderate sedation services (other than those services described by codes
00100 through 01999) provided by the same physician performing the
diagnostic or therapeutic service that the sedation supports, requiring the
presence of an independent trained observer to assist in the monitoring of
the patients level of consciousness and physiological status; younger than
5 years of age, first 30 minutes intra-service time
the patients level of consciousness and physiological status;age 5 years or
older, first 30 minutes intra-service time
the patients level of consciousness and physiological status, each
additional 15 minutes intra-service time (List separately in addition to code
for primary service)
00100 through 01999) provided by a physician other than the health care
professional performing the diagnostic or therapeutic service that the
sedation supports; younger than 5 years of age, first 30 minutes intraservice time
sedation supports; age 5 years or older, first 30 minutes intra-service time

CPT
Code
99150

CPT Code Description

sedation supports; each additional 15 minutes intra-service time (List
separately in addition to code for primary service)
The dental codes for sedation are

Dental
Code
D9230
D9241
D9242
Dental Code Description

Analgesia, anxiolysis, inhalation of nitrous oxide.
Reimbursement includes monitoring and management.
Intravenous conscious sedation/analgesiafirst 30 minutes
Allowed once per date of service
Allowed only in an office setting
Intravenous conscious sedation performed in the dental office must
include documentation in the record of pharmacologic agents, IV site,
monitoring of vital signs, and complete anesthesia time.
Reimbursement includes all drugs and/or medicaments necessary for
adequate anesthesia.
Reimbursement includes monitoring and management.
Intravenous conscious sedation/analgesiaeach additional 15 minutes
Allowed only in an office setting
Allowed up to a total of six (6) hours of anesthesia time
D. Modifiers
Providers are required to follow applicable modifier guidelines.
E. Place of Service
Office, hospital, outpatient hospital, ambulatory surgical center, nursing facility
F. Reimbursement
Providers must bill their usual and customary charges.
G. Billing Guidelines
Medicaid will not reimburse for moderate sedation codes 99143 through 99145 when billed
with codes in Appendix G of the CPT manual.
Medicaid will not reimburse for moderate sedation codes 99148 through 99150 when billed
in conjunction with codes in Appendix G when performed in the nonfacility setting.
Use 99143 through 99145 for sedation services provided by a single physician and a trained
observer.
Use 99148 through 99150 for sedation services provided by two physicians and a trained
observer.
99143 through 99150 are not billable with 00100 through 01999 or 94760 through 94762.
11202007
10

Division of Medical Assistance Clinical Coverage Policy No.: 1L-2 Moderate (Conscious) Sedation Original Effective Date: December 1, 2007

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Division of Medical Assistance Clinical Coverage Policy No.: 1L-2 Moderate (Conscious) Sedation Original Effective Date: December 1, 2007

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Formats disponibles

Division of Medical Assistance

Moderate (Conscious) Sedation

Clinical Coverage Policy No.: 1L-2

Definition of the Service..................................................................................................................1

Eligible Recipients ...........................................................................................................................3

When the Service Is Covered...........................................................................................................4

When the Service Is Not Covered....................................................................................................4

Requirements for and Limitations on Coverage ..............................................................................5

Providers Eligible to Bill for the Service .........................................................................................7

Additional Requirements .................................................................................................................7

Policy Implementation/Revision Information..................................................................................8

Attachment A: Claims-Related Information .................................................................................................9